The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?
The nurse waits 5 minutes between administering prescribed eye drops.
The nurse leaves the eye shield in place while the client sleeps.
The nurse is instructing the client not to drive at night.
The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.
The Correct Answer is D
Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.
Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.
Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.
Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Limiting fluid intake in the evening may reduce the need to urinate at night but does not address the client's fear of falling. It is more important to provide a safer alternative for nighttime voiding.
Choice B reason: Putting the side rails up and instructing the client to call the nurse before voiding may help, but it does not provide the most immediate and practical solution. A bedside commode offers a safer and more accessible option.
Choice C reason: Obtaining a bedside commode for the client's use directly addresses the client's concern about falling. It allows the client to void safely without having to walk to the bathroom at night, reducing the risk of falls.
Choice D reason: Leaving a nightlight on in the room can help improve visibility but does not completely eliminate the risk of falling. A bedside commode is a more effective solution.
Correct Answer is C
Explanation
Choice A reason: The statement "Use of eye drops will improve vision over time" is incorrect. Eye drops for glaucoma help to manage intraocular pressure but do not typically improve vision. They are used to prevent further vision loss.
Choice B reason: The statement "Double vision is a common symptom of glaucoma" is incorrect. Double vision is not a typical symptom of glaucoma. Glaucoma primarily affects peripheral vision.
Choice C reason: The statement "Without treatment, glaucoma can cause blindness" is accurate. Glaucoma is a leading cause of blindness if not treated properly. Managing intraocular pressure is crucial to prevent damage to the optic nerve.
Choice D reason: The statement "Glaucoma is caused by inadequate production of fluid within the eye" is incorrect. Glaucoma is usually caused by increased intraocular pressure due to inadequate drainage of the aqueous humor within the eye.
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